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Techniques Of Harvesting
Cartilage Graft For
Cartilage Tympanoplasty
Dr. Erami M.D.
ENT Resident
Department Of ENT
Shahid ...
•Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• The tissue rigidity of cartilage and its resistance to retractio...
•Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
2. If a second-stage ossiculoplasty with an allograft is anticipat...
•Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• more recent literature supports the use of cartilage for:
• the ...
•Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• Numerous techniques and types of cartilage grafting have
been de...
•Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• Cartilage may be harvested with its attached perichondrium
from ...
•Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• The cartilaginous graft can be made quite thin and of a small
en...
•BIOMECHANICS OF CARTILAGE:
•- Thickness, mass effect
Thick graft
More stable
Greater reflection
Less acoustic sensitivity...
• All three approaches can be applied
in Cartilage tympanoplasty
Transmeatal or
transcanal
endaural retroauricular
•In mastoidectomy, antrotomy, and atticotomy:
• most surgeons will employ a retroauricular approach.
•Plester Technique
After a retroauricular fold incision
At the level of 4-5 mm medially
to the suprameatal spine, a
circum...
After a superior vertical incision
and an inferior vertical incision,
a large tympanomeatal flap
is elevated together with...
•Palva’s Swing-Door
Technique
After a retroauricular fold incision
performed a radial incision at the:
9-o’clock position
...
•Wullstein—KIey technique
• retroauricular fold incision
• the bony ear canal is
widened by drilling for 2-3 mm
• circumfe...
Transmeatal Approach through Fixed Ear Speculum
Cartilage may be harvested from the tragus or the concha.
• Sites for harvesting
the cartilage in the right
auricle seen on the front
side.
• C: concha
• CY: cymba
• TE: triangular...
• Lines 1 and 2:
• Resection of the most anterior 3-4
mm and 4-5 mm, used after
canal wall down mastoidectomy
to prevent s...
•Harvesting of Tragal Cartilage:
•Tragal cartilage seems to be used more often than conchal
cartilage, mainly because :
•i...
•In cartilage Tympanoplasty
•A small or medium-sized tragus graft:
•can be harvested during the endaural approach by
expos...
Harvesting a large tragal
cartilage graft with a 15 mm
incision 2 mm medial to the
dome.
The large incision is made
in one...
Using a pair of scissors,
the extra perichondrial
tissue is elevated on both
sides of the tragus
First :
The tragus is cut
along the superior border
Then:
The tragus is cut
along the the inferior
Using pincers the tragus is
pulled outward and cut
along the medial border
• Harvesting the tragus cartilage:
• Heermann endaural approach
(through the intercartilaginous
incision)
• The superior e...
•The cartilage is cut
along the medial
border using a pair of
scissors.
•A vertical incision
made with a scalpel
in the inferior part
of the tragus
completely
mobilizes the tragal
graft.
Heermann’s approachHarvesting of Tragal Cartilage
• Harvesting of Cartilage from the Auricle Cartilage :
• can be harvested from various sites of the
posterior side of the ...
•Harvesting of Conchal Cartilage:
•Conchal cartilage than tragal cartilage is :
•slightly thicker
•more convex
but it is a...
• Harvesting of conchal cartilage
via a retroauricular approach:
• Both sides are covered with perichondrium.
• Harvesting of the cymba cartilage and the fossa triangularis
cartilage:
• Incision of the skin is:
slightly superior to ...
• The dashed line:
• the eminence of the
triangular fossa (FT).
• The dotted line:
• the eminence of the
scapha (S).
•Harvesting of Fossa Triangularis (FT) Cartilage:
•The eminence of the FT
•is positioned superiorly
to the cymba.
•It star...
•Harvesting of cartilage from the eminence of the scapha:
• After a 20 mm long skin incision:
on the eminence of the scaph...
• fossa triangularis cartilage than tragal cartilage is:
• thinner and has less mass.
• In the paper, Moore et al. reporte...
•HARVESTING CARTILAGE THROUGH ENDAURAL APPROACH
• TRAGAL CARTILAGE
• Heermann’s approach
• CONCHAL CARTILAGE
• Heermann’s ...
• Endaural Approach with Intercartilaginous Incision
Lempert incision
• Endaural Approach with Intercartilaginous Incision
The Farrior incision The Shambaugh incision
•Harvesting conchal cartilage in the endaural approach with
the Heermann incision.
• The ear canal skin is elevated
outwar...
•HarvestIng conchal cartilage ¡n the Shambaugh endaural
approach.
• The skin is elevated outward
from the helixand the
con...
•Harvesting conchal cartilage in the Farrior endaural
approach.
• A relatively long lateral
radial skin incision and
eleva...
•Thinning the Cartilage
•Thickness of graft:
• Ideal thickness 500-600 µm
• Stiffness same as tympanic membrane
• Impendin...
•Methods of thinning the graft:
1. Scalpel
2. Hildmann cartilage clamp
3. Kurz precise cartilage knife
4. Hüttenbrink cart...
•Scalpel:
• Held between two fingers
• Held between surgical forceps
• The Hildmann cartilage slicing clamp.
• a Open clamp
• b The clamp holds the cartilage
with the perichondrium to be
slic...
• Kurz Precise Cartilage Knife:
• The upper part of the
two-piece cutting block is
positioned at right angles
to the lower...
•The razor blade is fixed
¡n the blade holder with a screw.
• First
the lower and the upper
cutting blocks are aligned
• Then
the blade holder with the
blade is placed into the slits...
•Distance plates.
• Metal plates of the same shape
and area as the recess of the
lower cutting block and of
thickness 0.1,...
•The 0.6 mm thick cartilage
and a 0.1 mm thick
distance plate(arrow)
are removed from the
recess of the cutting block,
aft...
•The Hüttenbrink Cartilage Guide
a. 2 cylinders, one
inserted into another
b. Press the upper cylinder
c-d. Thin cartilage...
•The Groningen Cartilage Cutting Device
• Place cartilage in depression b
• Depression has diameter
4 mm and 0.5 mm deep
•...
Technique of harvesting cartilage graft  for cartilage tympanoplasty Dr. M. Erami
Technique of harvesting cartilage graft  for cartilage tympanoplasty Dr. M. Erami
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Technique of harvesting cartilage graft for cartilage tympanoplasty Dr. M. Erami

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Technique of harvesting cartilage graft for cartilage tympanoplasty Dr. M. Erami

  1. 1. Techniques Of Harvesting Cartilage Graft For Cartilage Tympanoplasty Dr. Erami M.D. ENT Resident Department Of ENT Shahid Sadoghi Hospital Yazd Iran
  2. 2. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY) • The tissue rigidity of cartilage and its resistance to retraction, even in the setting of ongoing eustachian tube dysfunction, has led to the growing acceptance of its use in middle ear reconstruction. • Some of indications: 1. Cartilage grafts placed between the TM and an ossicular prosthesis decrease extrusion risk and can augment the prosthesis-tissue interface, which allows for better long-term hearing results.
  3. 3. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY) 2. If a second-stage ossiculoplasty with an allograft is anticipated: • a cartilage graft may be placed beneath the central portion of the membrane at the time of tympanoplasty. 3. In addition to the more common uses of cartilage: • provide structural support to attic defects and posterosuperior retraction pockets
  4. 4. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY) • more recent literature supports the use of cartilage for: • the atelectatic ear and other conditions associated with increased failure rates with traditional techniques :  revision surgery  perforation >50%  drainage at time of surgery  bilateral perforations  reconstruction after cholesteatoma (although more controversial)
  5. 5. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY) • Numerous techniques and types of cartilage grafting have been described, the most common of which include: either placement of composite cartilage/perichondrial grafts of varying sizes and shapes or creation of cartilage palisade arrays.
  6. 6. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY) • Cartilage may be harvested with its attached perichondrium from the tragus or the concha. • Tragal cartilage than conchal cartilage: • Thicker • flatter • Tragal cartilage may be : • more suitable for larger perforations
  7. 7. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY) • The cartilaginous graft can be made quite thin and of a small enough diameter to bolster only the weakened portion of the involved TM, or it may be shaped to fill a pantympanic perforation. • Reducing cartilage thickness optimizes: • the acoustic-transfer properties • with thicknesses of 500 μm or less resulting in a highly favorable vibratory transfer.
  8. 8. •BIOMECHANICS OF CARTILAGE: •- Thickness, mass effect Thick graft More stable Greater reflection Less acoustic sensitivity Thin graft Less stable Lesser reflection Greater acoustic sensitivity
  9. 9. • All three approaches can be applied in Cartilage tympanoplasty Transmeatal or transcanal endaural retroauricular
  10. 10. •In mastoidectomy, antrotomy, and atticotomy: • most surgeons will employ a retroauricular approach.
  11. 11. •Plester Technique After a retroauricular fold incision At the level of 4-5 mm medially to the suprameatal spine, a circumferential incision of the meatal skin from the 12-o’clock to the 6-o’clock Position
  12. 12. After a superior vertical incision and an inferior vertical incision, a large tympanomeatal flap is elevated together with the fibrous annulus and eardrum
  13. 13. •Palva’s Swing-Door Technique After a retroauricular fold incision performed a radial incision at the: 9-o’clock position elevated a large superior and inferior tympanomeatal flap provides an excellent view of the anterior part of the: • tympanic cavity • fibrous annulus
  14. 14. •Wullstein—KIey technique • retroauricular fold incision • the bony ear canal is widened by drilling for 2-3 mm • circumferential incision is made about 10 mm medial to the spine • A small lateral radial incision at the 1 2 & 6-o’clock position • skin flap is pulled outward • A superior incision of the skin is continued outward.
  15. 15. Transmeatal Approach through Fixed Ear Speculum
  16. 16. Cartilage may be harvested from the tragus or the concha.
  17. 17. • Sites for harvesting the cartilage in the right auricle seen on the front side. • C: concha • CY: cymba • TE: triangular eminence • S: scapha • T: tragus • A: antitragus • CH: crus of the helix
  18. 18. • Lines 1 and 2: • Resection of the most anterior 3-4 mm and 4-5 mm, used after canal wall down mastoidectomy to prevent stenosis. Lines 1and 2 do not involve the crus of the helix. • Lines 3 and 4: • used when treating stenosis after previous canal wall down mastoidectomy. Considerable areas of cartilage are removed, including part of the crus of the helix. • Lines 5a and 5b: • involve the entire concha, taken as graft material.
  19. 19. •Harvesting of Tragal Cartilage: •Tragal cartilage seems to be used more often than conchal cartilage, mainly because : •it is harvested along the same route as that of the transcanal and the endaural approaches. •tragal cartilage is less convex than conchal cartilage. •For cosmetic reasons, the incision is most often made: • 2-3 mm medial to the tragal dome
  20. 20. •In cartilage Tympanoplasty •A small or medium-sized tragus graft: •can be harvested during the endaural approach by exposing the superior edge of the tragus or the inferior edge of the concha. •For the removal of a large piece of tragal cartilage: •the incision is 15mm long. •Using a pair of scissors •the extraperichondrial plane is created on both sides and the cartilage graft is excised.
  21. 21. Harvesting a large tragal cartilage graft with a 15 mm incision 2 mm medial to the dome. The large incision is made in one sweep through the skin and the cartilage with the perichondrium
  22. 22. Using a pair of scissors, the extra perichondrial tissue is elevated on both sides of the tragus
  23. 23. First : The tragus is cut along the superior border Then: The tragus is cut along the the inferior
  24. 24. Using pincers the tragus is pulled outward and cut along the medial border
  25. 25. • Harvesting the tragus cartilage: • Heermann endaural approach (through the intercartilaginous incision) • The superior edge of the tragus is first separated from the fibrous tissue of the intercartilaginous region • tragus is grasped and pulled in superior direction • subcutaneous tissue is elevated from the dome anteriorly and posteriorly
  26. 26. •The cartilage is cut along the medial border using a pair of scissors.
  27. 27. •A vertical incision made with a scalpel in the inferior part of the tragus completely mobilizes the tragal graft.
  28. 28. Heermann’s approachHarvesting of Tragal Cartilage
  29. 29. • Harvesting of Cartilage from the Auricle Cartilage : • can be harvested from various sites of the posterior side of the auricle : • Eminence of the concha • Eminence of the cymba concha • Eminence of the triangular fossa • Eminence of the scapha • From the anterior side of the auricle: large parts of the conchal cartilage can be removed ¡n various endaural approaches.
  30. 30. •Harvesting of Conchal Cartilage: •Conchal cartilage than tragal cartilage is : •slightly thicker •more convex but it is always • large enough for any composite graft
  31. 31. • Harvesting of conchal cartilage via a retroauricular approach: • Both sides are covered with perichondrium.
  32. 32. • Harvesting of the cymba cartilage and the fossa triangularis cartilage: • Incision of the skin is: slightly superior to the eminence of the concha. • Subcutaneous tissue: is elevated • The perichondrium is exposed ( of the superior part of the eminence of the concha and of the cymba cartilage). • With a circular incision: The most convex part—the cymba cartilage—is cut and removed.
  33. 33. • The dashed line: • the eminence of the triangular fossa (FT). • The dotted line: • the eminence of the scapha (S).
  34. 34. •Harvesting of Fossa Triangularis (FT) Cartilage: •The eminence of the FT •is positioned superiorly to the cymba. •It starts at the anterior crus of the antihelix •It ends at the posterior crus •of the antihelix.
  35. 35. •Harvesting of cartilage from the eminence of the scapha: • After a 20 mm long skin incision: on the eminence of the scapha • skin and subcutaneous tissue are elevated • exposing an area of 20 mm x 5 mm to allow cutting and removal of a 20 mm x5 mm piece of cartilage.
  36. 36. • fossa triangularis cartilage than tragal cartilage is: • thinner and has less mass. • In the paper, Moore et al. reported good anatomical and functional results ¡n tympanoplasty of 83 patients with fossa triangularis cartilage ¡n total perforations • cartilage palisade arrays:
  37. 37. •HARVESTING CARTILAGE THROUGH ENDAURAL APPROACH • TRAGAL CARTILAGE • Heermann’s approach • CONCHAL CARTILAGE • Heermann’s approach • Shambaugh’s/ Lempert’s approach • Farrior approach
  38. 38. • Endaural Approach with Intercartilaginous Incision Lempert incision
  39. 39. • Endaural Approach with Intercartilaginous Incision The Farrior incision The Shambaugh incision
  40. 40. •Harvesting conchal cartilage in the endaural approach with the Heermann incision. • The ear canal skin is elevated outward exposing conchal Cartilage which is removed With the perichondrium.
  41. 41. •HarvestIng conchal cartilage ¡n the Shambaugh endaural approach. • The skin is elevated outward from the helixand the conchal cartilage. • The lateral radial incision of the conchal skin allows resection of a large piece of the conchal cartilage.
  42. 42. •Harvesting conchal cartilage in the Farrior endaural approach. • A relatively long lateral radial skin incision and elevation of the lateral ear canal skin allow easy exposure and removal of the conchal cartilage.
  43. 43. •Thinning the Cartilage •Thickness of graft: • Ideal thickness 500-600 µm • Stiffness same as tympanic membrane • Impending Eustachian tube dysfunction: • High chances of graft retraction • Thicker cartilage >500 µm stable reconstruction
  44. 44. •Methods of thinning the graft: 1. Scalpel 2. Hildmann cartilage clamp 3. Kurz precise cartilage knife 4. Hüttenbrink cartilage guide 5. Groningen cartilage cutting device
  45. 45. •Scalpel: • Held between two fingers • Held between surgical forceps
  46. 46. • The Hildmann cartilage slicing clamp. • a Open clamp • b The clamp holds the cartilage with the perichondrium to be sliced from above with a scalpel • c A cartilage island graft with a perichondrium flap is sliced from above. • d The island graft is sliced from below
  47. 47. • Kurz Precise Cartilage Knife: • The upper part of the two-piece cutting block is positioned at right angles to the lower part to illustrate the location of the recess of the cutting block into which the cartilage is placed(thick arrow) • The guiding slits (thin arrow) where the razor plate will be placed. • After placement of the cartilage, the upper cutting block is turned in the direction of the curved arrow.
  48. 48. •The razor blade is fixed ¡n the blade holder with a screw.
  49. 49. • First the lower and the upper cutting blocks are aligned • Then the blade holder with the blade is placed into the slits of the cutting block. • With sawing movements of the blade in directions of the horizontal arrows the cartilage is sliced.
  50. 50. •Distance plates. • Metal plates of the same shape and area as the recess of the lower cutting block and of thickness 0.1, 0.2, and 0.3 mm compared with the cartilage of 0.7 mm cut without the use of distance plates.
  51. 51. •The 0.6 mm thick cartilage and a 0.1 mm thick distance plate(arrow) are removed from the recess of the cutting block, after completion of cutting with the distance plate.
  52. 52. •The Hüttenbrink Cartilage Guide a. 2 cylinders, one inserted into another b. Press the upper cylinder c-d. Thin cartilage plate obtained 2.5mm×3.5 mm, 0.3 mm thick, central 0.8 mm hole for titanium prosthesis
  53. 53. •The Groningen Cartilage Cutting Device • Place cartilage in depression b • Depression has diameter 4 mm and 0.5 mm deep • No 11 blade used to cut off the upper part

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